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ECMO (Extracorporeal membrane oxygenation)

ECMO is a very advanced form of life support that is essentially a heart-lung bypass machine. It’s often used during open heart surgery, but can also be used in situations where patients are incredibly hypoxemic. The ECMO machine itself is often referred to as a “circuit”; this circuit delivers blood from the patient through the “ECMO lung” and then back to the patient. It is essnetially like dialysis for the lungs; it addes oxygen and removes carbon dioxide.

There are two types of ECMO:

• V-V (venovenous) ECMO: no hemodynamic support, purely oxygenation/ventilation; replaces lungs

• V-A (venoarterial) ECMO: hemodynamic support; replaces heart and lungs

ECMO is only available at PAH or Emory. In order to refer a patient for ECMO, you must call the ECMO team to determine if they are a candidate.

Each ECMO team will have their own guidelines in place so it’s important to call and check for candidacy no matter what. In general, in order to be an ECMO candidate, the general considerations are:

1. Hypoxic Respiratory Failure due to any cause (primary or secondary) when risk of mortality is>50%

   1. 50% Mortality: P/F ratio<150 on FiO2>90% and/or Murray score 2-3

   2. 80% Mortality: P/F ratio<100 on FiO2>90% and/or Murray score 3-4 despite optimal care for 6+ hours

2. CO2 retention on mechanical ventilation despite high Pplat (>30cm H2))

3. Severe Air Leak syndromes

4. Need for intubation in a patient on lung transplant list

5. Immediate cardiac or respiratory collapse (PE, blocked airway, unresponsive to optimal care)

There are no absolute contraindications to ECMO. Relative contraindications are:

1. Intubated at high settings (FiO2>90%, Pplat>30) f0r 7 days or more

2. Major pharmacologic immunosuppression (abs neutrophil count<400/mm3)

3. CNS hemorrhage - recent or expanding

4. Non recoverable co-morbidity such as major CNS damage or terminal malignancy

5. Age: no specific age contraindication but consider increasing risk w/increasing age

Supporting Docs

• ELSO Guidelines for Acute Respiratory Failure

• ELSO Guidelines for ECMO Transport

• Organization of ECMO Programs for ARF

• Feasibility of inter-hospital transportation using ECMO support of patients affected by severe swine-flu (H1N1) related ARDS

• Retrieval of critically ill adults using ECMO - an Australian Experience

• GLA ECLS/ECMO Transfer Position Paper: Draft v1.0

• GLA ECLS/ECMO Transfer Position Paper: Draft v3.0

• ICN ECMO Powerpoints

• ECMO for Pandemic Influenza A (H1N!) Induced ARDS - France

Setting up Networks

• A Review of 100 transported on ECMO

• Interest of a simple on-line screening registry for measuring ICU burden related to influenza pandemic

• ECMO in H1N1 Provoked Acute Resp Failure

• Emergency circulatory support in refractory cardiogenic shock patients in remote institutions: a pilot study (the cardiac-RESCUE program)

Transport Studies

• Safe Transport of Critically Ill Adult Patients on ECMO Support to a Regional ECMO Center

• Inter-hospital transportation of patients with severe ARF on ECMO - national and international experience

• The French airbridge for circulatory support in the Carribean

• ECMO for Interhospital transfer for severe ARDS patients: a 5 year experience

• A 22 year experience in global transport ECMO

• A 16 year neonatal/pediatric ECMO transport experience

• Transportation of critically ill patients on ECMO

Transport Vents

• Fractional inspired O2 on transport vents: an important determinant of volume delivery during assist control ventilation with high resistive load

• Evaluation of ventilators used during transport of ICU patients - a bench study